by Tyler Norris and Mary Pittman, DrMPH, Public Health Reports, Vol. 115, March/April and May/June 2000
Synopsis: Part One of this article describes the principles and origins of the Healthy Communities movement. Part Two describes the Coalition for Healthier Cities and Communities, a national network of partnerships and organizations. The authors argue (a) that to sustain community initiatives, practitioners must move from projects that address symptoms of social problems to changing the underlying community cultures, incentives, and settings that give rise to these symptoms, and (b) that the Coalition's continued relevance depends on its ability to help leaders make that transition.
Now in its second decade, the Healthy Communities movement is transforming communities across the nation. Its goal is ambitious: to achieve radical, measurable improvement in health status and long-term quality of life. And by many measures of health and well-being, it's working. From Alaska's Kenai Peninsula to sunny Orlando, from rural Kansas to inner-city Detroit, Healthy Communities initiatives are translating local values and resources into action for positive outcomes. These outcomes are being measured in many ways, including citizens' self-reports of improvements in social cohesion, trust, and "sense of community" and tangible progress on tough health issues - including reduced crime rates, lower teen pregnancy rates, declining numbers of new HIV infections, and improved cardiovascular health. Success in these areas can be attributed at least in part to Healthy Communities efforts.
At the local level, the movement has facets as diverse as the more than 1,000 communities embracing its principles. Healthy Cities/Healthy Communities initiatives typically have a health status improvement focus. "Sustainable community" initiatives take action at the intersection of economic health, environmental quality, and social equity. Architects and city planners looking at the physical design of the community and its impact on quality of life are working for "livable communities." The Carter Center/Emory University interfaith health efforts refer to creating "whole communities." In reality, the nation's community initiatives and multisectoral partnerships go by hundreds of names, depending on local perspective, focus, and goals. Cumulatively, though, locale by locale, this nationwide movement is changing the way citizen leaders effect positive change. Whether at the level of personal decision, corporate practice, or collaborative partnership, building a healthier community has become an expressed priority across the country.
The choices we make at home, work, school, play, and worship determine most of what creates personal health and community vitality. Healthy communities result from healthy choices and environments that support shared responsibility. Everyone has a role to play in building a healthier, more vibrant community. To a great extent, it's about how we spend our time, dollars, and talents. But it's also about how we create settings in our communities that are conducive to making positive change. Growing a healthy community is a lifelong process-one that requires constant nurturing and vigilance.
Healthy communities are powerful because they help unleash human potential. They build trust and relationships. They mobilize the creativity and resources of the community toward a shared vision for the future. Healthy Communities call for inspired leadership from every corner of the community.
Today, there is a gulf between the conversations people have around their kitchen tables and the formal processes of governance. There are turf battles and fragmentation of efforts. Resources are spent more on the symptoms of deeper problems and less on what generates health in the first place. The result is often community dysfunction that favors the status quo. At its core, the Healthy Communities movement is a philosophy for building communities that are capable of addressing community problems. Healthy communities engage the voices and talents of the community. They generate ideas and relationships across lines that divide us; they lead to action for positive change by giving a focus to what communities aspire to, and are achieving. Acting upon a shared vision for the future is the foundation upon which a healthier community is built.
The Healthy Communities movement takes a broad view of health and employs a cross-section of human endeavors to achieve improved health status and community quality of life. Medical care is just one of the many formal and informal community resources that contribute to building a healthier community. These resources include, but are not limited to: cultural norms that support behavior and lifestyle choices; education, learning, and skill building; safe and adequate housing; recreation and culture; public safety; youth mentors; volunteers; the workplace; jobs that pay a living wage; family; nonprofit organizations; health promotion and preventive services; the faith community; media; government; and transportation.
Effective local and regional collaborations bridge sector, race, and class divisions. They develop innovative strategies to address complex issues. They tackle the vexing issues that no single institution, sector, program, or grant can handle alone. They work to generate health as a byproduct of people's lives and communities working.
History. Formally, the movement began in the mid-1980s, inspired by Drs. Len Duhl and Trevor Hancock and first implemented via the Healthy Cities initiative spearheaded by the World Health Organization. That effort was designed to bolster quality of life in 34 European cities. Since that time, the movement has spread to more than 3,000 communities in more than 50 countries on every continent. In the US, it has a distinctive American flavor embracing traditions of local democracy and citizen governance.
While part of its inspiration came from abroad, the rapid growth of the Healthy Communities movement in the US can be attributed to its rootedness in American traditions and values. Healthy Communities initiatives are a modern illustration of what, in 1831, Alexis de Tocqueville observed made America unique and prosperous: its associational life-the way citizens come together to engage in meaningful work for the benefit of community. Indeed, it's our cultural heritage to believe that, with persistence, we can achieve a better life for our children, our community, and ourselves.
The US Department of Health and Human Services formally embraced the Healthy Communities concept in 1989, asking the National Civic League to help launch the US Healthy Communities Initiative. Healthy Boston, California Healthy Cities, and the WHO Collaborating Center at Indiana University paved the way for the nascent US movement.
Since then, hundreds of community partnerships, health care organizations, human services and public health agencies, and community-based organizations have adopted the Healthy Communities approach to community building. Early on, key national institutional leaders included the Health Research and Educational Trust, V HA, Inc., the Health Forum, and the National Civic League. Federal partners included the Office of Disease Prevention and Health Promotion at the Centers for Disease Control and Prevention and the Health Resources and Services Administration. The W.K. Kellogg Foundation, Robert Wood Johnson Foundation, and the Colorado Trust made significant early grants to important initiatives.
As Healthy Communities gained momentum across the US, it became clear that the movement would be strengthened by the creation of a national network of community and organizational leaders. In 1994, Tyler Norris, Mary Pittman, and Len Duhl began a conversation that would lead in 1996 to the formation of the Coalition for Healthier Cities and Communities (CHCC). The CHCC brings together more than 1,000 local, state and national organizations, collaborative partnerships, and citizens to assist local efforts in creating healthier communities by improving the economic, social, and physical well-being of people and places.
The CHCC's purpose is to be a link to resources, a public policy voice, and a facilitator of Healthy Communities efforts nationwide. Instead of operating as a membership organization from a centralized location, the CHCC acts as a clearinghouse for communities and movement leaders who choose to avail themselves of its resources and services. Thirty people from across the country make up the Coordinating Council, the CHCC's decision-making body: Council members who communicate through e-mail and monthly teleconferences and come together at conferences twice a year. Thirty states are represented by network liaisons to the CHCC who support state and local level Healthy Communities initiatives by providing training, education, and policy assistance.
The Coalition is supported by a rapidly growing membership base, diverse leadership, a solid governance structure, a small professional staff, and has an active research, development and communication agenda. The Health Research and Educational Trust of the American Hospital Association serves as the Coalition Secretariat.
The CHCC stimulates and encourages collaborative action and efficient use of resources from multiple sectors and community systems. It works non-hierarchically
and promotes a democratic energy essential to fostering the activity of community groups and creative leadership. It is a network that brings together seasoned and new leaders and community health workers-all convened to learn new skills through the sharing of experience and know-how.
CHCC partners report that the Coalition is an important element in shaping private sector and public policy in their efforts to put Healthy Communities principles
into action. Policy change at the national level is crucial to enable progress at the local level. Organizations and government access the Coalition as a resource to think
through those issues that involve multiple sectors and to bring a unified advocacy voice to future endeavors. Through the Coalition, partners can develop a collective voice that represents experience and diversity. The CHCC hopes that by facilitating the efficient assembly of resources and the cultivation of extensive collaboration and information sharing, the once-local Healthy Communities phenomenon will evolve into a nationally organized and informed movement to improve health and quality of life.
Support for the CHCC comes from agencies of the US Department of Health and Human Services, various hospital associations and public health organizations, and private corporations and foundations.
As a link to resources, the Coalition provides access to a rich learning base and compilation of case studies, success stories, best-practices information, educational materials, training programs, process tools, individual practitioners, "outcomes" research, progress measures, and standardized datasets. Via www.healthycommunities.org and a vast network of active participants, the Coalition's reach and ability to deliver these resources is increasingly of great value to action at the local level.
As a voice for policy and action, the Coalition cuts across sectoral and partisan boundaries to support the development of a shared agenda for the health of our communities. Beyond having member groups merely share their policy agendas with each other, the CHCC provides a forum for critical thinking and dialogue across
the lines that often limit creative policy development and implementation.
As a force for helping create and sustain effective local change initiatives, the Coalition is emerging, on behalf of local and statewide initiatives, as a springboard from which citizen, business, and organizational leaders can develop and refine community strategies and build alliances with others to formulate and advance effective policy at the local, state, and national levels. Local community initiatives have said that this collective voice is key to enable their work. In response, the Coalition is becoming a critical and potent base from which to build a policy agenda.
CHCC's Healthy Communities Agenda campaign. In 1999, CHCC partners conducted more than 300 dialogues, engaging 4,000 people from around the us to (a) stimulate action toward building healthy communities on the local level and (b) articulate what communities themselves say about what factors lead to improving quality of life. The dialogues identified seven characteristics of a healthy community; according to participants, a healthy community:
- practices ongoing dialogue among residents to build relationships and a shared vision of what the community is, what it should be, and how to get there.
- generates leadership within the community, fosters a leadership style that emphasizes facilitation and collaboration, and encourages coalitions and
- shapes its future based on a shared vision of the community.
- embraces the diversity of its residents.
- gathers information about its assets and needs.
- connects people to community resources.
- creates a sense of responsibility and belonging among its residents.
Sustain efforts. With Healthy Communities initiatives now underway in all corners of the nation, the challenge for the future is to sustain these maturing efforts in a way that makes health and quality of life a determining factor in life choices, organizational practices, and policymaking/resource allocation decisions at all levels. Leaders in many locales will need to transition from managing projects that address symptoms of deeper underlying challenges to actually changing the community cultures, incentives, and settings that give rise to the issues in the first place. They will need to develop community investment strategies that measurably build community health, wealth, and well-being. They will need to partner with the institutions that make up the public's health infrastructure. The local challenge is not so much about sustaining the initiatives themselves as sustaining the positive change they are created to generate.
Align incentives. The next step is to align the incentives of health care providers with the public health and Healthy Communities emphasis on improving population health status and quality of life. Doctors and hospitals are rewarded for their efforts to cure disease, but their financial incentive is to treat illness, not produce health. The question is whether and how partnerships and institutions realign incentives. We must develop reimbursement mechanisms that will allow for a fair return on investment to providers and measurements that document the sustained development and resultant outcomes of community improvement initiatives.
Support from CHCC. Nationally, the future of the CHCC rests on the extent to which it effectively supports its partners in creating systemic positive change. The strong network of professional and institutional relationships built through the CHCC will endure. These
relationships have led to many outcomes, such as the CHCC's partnership with the US Health Resources and Services Administration on the Children's Health Insurance Program and the 100% Access/0 Disparities Initiative. But it is the dynamic of every coalition (whether local or national) to require a clear purpose and accessible structure that is compelling enough to attract core leadership. Otherwise, leaders choose to effect desired change via other vehicles.
For 2000-2001, the Healthy Communities Agenda campaign and the growing "states" structure will drive the dynamics of the Coalition. How CHCC partners translate the Agenda's findings into tools and resources, policy and practice options, and direct action will determine the ways in which the Coalition remains an indispensable resource to the Healthy Communities movement.
Healthy Cities projects were launched in 34 European cities by the World Health Organization in 1988.
Healthy Cities/Healthy Communities were redefined in an American context, and initiatives began to form throughout the US in 1988.
The International Healthy Cities and Communities Conference in December 1993 was the first formal meeting in the US of the Healthy Cities/Healthy Communities movement. The conference gathered community and organizational leaders from across the US and around the world.
The National Civic League's 100th Annual Meeting in November 1994 was the first time a formal Coalition planning meeting was held. Many of the people who would later design and establish the Coalition for Healthier Cities and Communities worked to build on dozens of informal conversations that had taken place in the preceding year. It was at this meeting that a core group of 25 leaders agreed on the concept of the Coalition.
A Leadership Action Forum (LAF) held in Washington, DC, in June 1996 became the official birthplace of the Coalition. The 150-plus LAF participants voted in favor of establishing the Coalition as an ongoing entity - in part carrying out the agenda for action developed via the LAF process. Mary Pittman, DrPH, President of the Health Research and Educational Trust, was name the first Coalition Chair.
The Coalition began the process of linking its regular meetings with the meetings of organizations from other sectors. The November 1996 Conference was held at the National Civic League's 102nd annual meeting. The meeting continued the core work of Action Teams developed in June at the LAF. Tyler Norris was named the Coalition's Executive Director.
In March 1997, the Coalition partnered with the Carter Center to attract leaders of the interfaith community. With that partnership, the Coalition added an additional strategic direction: to support the President's Summit for America's Future and America's Promise, its follow-up campaign.
In May 1997, the Coalition met prior to the Healthcare Forum's Healthier Communities Summit. The focus was on California success stories as well as community indicators and progress measures.
In December 1997, the Coalition met in conjunction with the communities of the Community Care Network (CCN) Demonstration Project. The theme was building training programs for community development and broadening the community knowledge of the health workforce. CCN is a collaboration of the Health Research and Educational Trust, VHA, Inc., and the Catholic Healthcare Association, with funding from the W.K. Kellogg Foundation.
In February 1998, www.healthycommunities.org was launched in partnership with America's Promise. This website was built for the movement and CHCC by a corporate consortium of Informix Software, Hewlett-Packard, Netscape, Fort Point Systems, and Evolve Creative Design. The site uses inter-relational database technology to gather and disseminate information about individuals and organizations involved in the Healthy Communities movement.
In March 1998, the Coalition held an Innovations Policy Forum in Washington, DC, with the theme "Healthy Communities: Building a Productive Workforce." This conference explored ways in which communities generate and sustain productive workforces and the variety of policies and solutions that build the basis for sustainable local economies. Proceedings, with innovative case examples, were disseminated in June 1998.
In March 1998, the Coalition announced its commitment to engaging community and organizational leaders in a broad-based "communities movement" over the next two years in developing a Healthy Communities Agenda for the nation. The Coalition recruited Michael McGinnis, MD MPH, now at the Robert Wood Johnson Foundation, and former director of the Office of Disease Prevention and Health Promotion, as an advisor to the project.
In March 1998, the CHCC published Community Indicators: An Inventory, which tracks successful community indicator projects working to improve health and quality of life. Developmental partners include the Delaware Valley Healthcare Council, the Institute for Healthy Communities, and the Health Research and Educational Trust.
The Coalition's State Network was launched in April 1998. Currently representing 34 states, the Network is working via "state liaisons" to develop mechanisms for information-sharing across states and for expanding the number of participating states.
Sampling the States: Local Reflections on State Implementation of Children's Health Insurance (SCHIP) was completed in July 1998. Funded by the US Health Resources and Services Administration, the publication is a report on a study that sampled 10 states' grass-roots perspectives of the impact of SCHIP on children's health and service delivery.
Voices from America: Ten Healthy Community Stories from Across the Nation, a collection of 10 case stories highlighting communities engaged in health improvement efforts, edited by Christopher Freeman Adams, was published in November 1998. The publications document the breadth of Healthy Communities projects, from hospital-initiated health improvement efforts to state-level policy changes.
In November 1998, the Coalition co-hosted the conference, "Building Healthier Communities: Ten Years and Learning," in collaboration with the National Civic League, the Health Resource and Educational Trust, and Community Care Network Demonstration Program. Here the Healthy Communities Agenda strategy was endorsed by scores of partners including the Surgeon General, David Satcher, MD.
In April 1999, more than 44,000 copies of the Healthy Communities Agenda: Dialogue Guide were printed and disseminated via partners nationwide. This Guide is the primary tool in supporting the Healthy Communities Agenda campaign. Monte Roulier was retained as the Dialogues Coach.
The Coalition Coordinating Committee, state liaisons, and other guests gathered in Boulder, CO, in August 1999 for a progress report on the Healthy Communities Agenda as well as to set priorities for the year 2000. These priorities include:
- advancing the message emerging from the Healthy Communities Agenda dialogues
- growing out network of states (now numbering more than 30 states)
- advancing the 100% Access to Health Care/Zero Disparities campaign
- working with the media to better communicate the Healthy Cities/Healthy Communities message in print and over the airwaves.
The Health Resource and Educational Trust and Health Forum of the American Hospital Association hosted 450-plus movement leaders at a conference in Chicago in December 1999 called "Transforming Communities: Improving Health and Quality of Life." John Kesler was named as Executive Director of the CHCC. The findings from a year's worth of dialogues, in which more than 4000 people from nearly 300 different communities participated, culminated in "A Message to America from America's Communities." Based on the results of the dialogues, Seven Patterns of a Healthy Community were determined.
In January 200, the Healthy Communities Agenda was released to the nation at the Office of Disease Prevention and Health Promotion's "Partnerships for Health in the New Millenium" conference in Washington, DC. Its release corresponded with the premier at the same conference of a Healthy Communities video, sponsored by the Coalition and generously funded by the ServiceMaster Company.
Healthy Communities groups ascribe to the following principles:
A broad definition of "health." Health encompasses not just the absence of disease, but the full range of quality if life issues, including lifestyle and behavior choices, genetic endowment, and the socio-economic, cultural and physical environment. Health is a byproduct of a wide array of choices and factors - not simply the result of medical intervention.
A broad definition of "community." Communities are inclusive and based on faith, perspective, profession, as well as geographic lines.
Shared vision from community values. A community's vision is the story of its desired future, reflecting the core values of its diverse members. It is a living expression of shared accountability to priorities.
Improved quality of life for everyone. Healthy communities strive to ensure that the basic emotional, physical, and spiritual needs of everyone in the community are attended to.
Diverse citizen participation and widespread community ownership. In healthy communities, all people take active and ongoing responsibility for them selves, their families, their property, and their community. A leader's work is to find common ground among participants so that everyone is empowered to take direct action for health and influence community directions.
Focus on "systems change." The Healthy Communities movement contemplates a different vision for the way people live and work together, how community services are delivered, how information is shared, how local government operates, and how business is conducted. It demands mat resource allocation and decision-making be spread throughout the community.
Development of local assets and resources. Healthy communities identify and build on a community's strengths and successes and then invest in the enhancement of a community's civic infrastructure. The idea is that, by developing an infrastructure that encourages health, fewer resources will need to be spent on "back end" services that attempt to fix the problems resulting from a weak infrastructure.
Benchmarks and measures of progress and outcomes. Healthy communities use performance measures and community indicators to help expand the flow of information and accountability to all citizens, as well as revealing whether residents are heading toward or away from their stated goals. Timely, accurate information is vital to sustaining long-term community improvement.
Mr. Norris is President of Community Initiatives, LLC., and was the founding Director of the Coalition for Healthier Cities and Communities (CHCC). Dr. Pittman is President of the Health Research and Educational Trust and Chair of the CHCC. Address correspondence to Mr. Norris, 2119 Mapleton Ave., Boulder, CO 80304; tel. 303-444-3366; fax 303-444-1001; email email@example.com
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